Women and tobacco: moving from policy to action Virginia Ernster,1 Nancy Kaufman,2 Mimi Nichter,3 Jonathan Samet,4 & Soon-Young Yoon5 A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic. Evidence is provided in this article for the negative impact of tobacco use by women and of passive smoking on the health of women and children. Use of tobacco by women is increasing and this is related to the tobacco industry’s aggressive advertising, sponsorship and promotion strategies. Policy directions are proposed in this article. At all levels, a multi-pronged strategy — including changes in legislation and fiscal policies, improvements in gender-sensitive health services, and cessation programmes — should be considered. Much more gender-specific research on tobacco use is needed, particularly in developing countries. Women’s empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the recently introduced Framework Convention on Tobacco Control. Keywords: smoking, epidemiology; tobacco, adverse effects; tobacco industry, economics; tobacco smoke pollution, adverse effects; women’s health; women’s rights. Voir page 898 le re´sume´ en franc¸ais. En la pa´ gina 898 figura un resumen en espan˜ ol. Introduction The importance of a gender perspective and the empowerment of women were the main The focus of the WHO International Conference on messages of the conference, which was marked by Tobacco and Health, which was held in Kobe, Japan, an increasing awareness among policy-makers of the on 14–18 November 1999, was ‘‘making a difference need to bring gender into the mainstream of tobacco to tobacco and health: avoiding the tobacco epidemic control policies. This article addresses issues con- in women and youth’’ (1). At this conference, cerning gender and tobacco control and suggests scientists, representatives from governments and actions for policy-making and implementation. The nongovernmental organizations (NGOs), as well as underlying assumption is that gender relations — tobacco control activists called for a global effort to defined as roles and responsibilities that are socially prevent a rising epidemic of tobacco use among determined between men and women — affect the women and youth. The Kobe Declaration stated: prevalence, determinants, treatment and eventual ‘‘There are already over 200 million women smokers, outcome of tobacco-related diseases among women and tobacco companies have launched aggressive (2). Gender is institutionally structured and is a campaigns to recruit women and girls worldwide. By complex array of values and norms that permeate the year 2025, the number of women smokers is social structures and organizational systems, includ- expected to almost triple... It is urgent that we find ing legal, political, economic, health and religious comprehensive solutions to the danger of tobacco systems. A gender perspective in tobacco control use and address the epidemic among women and policies will contribute to a more accurate epidemio- girls. Tobacco has been identified as a contributing logical understanding of tobacco use as well as to factor to gender inequity and undermines the making programmes more successful. principle of women and children’s right to health as a basic human right’’ (1). Tobacco use by women Rising prevalence and impact of smoking 1 Professor and Vice-Chair, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, on women’s health CA 94143, USA (email: [email protected]). Correspondence Projections by WHO for the 1990s gave global should be addressed to this author. estimates of the proportions of smokers as 47% 2 Vice-President, The Robert Wood Johnson Foundation, Princeton, NJ, among men and 12% among women (3). However, USA. the prevalence of smoking among women is much 3 Assistant Professor, Department of Anthropology, University higher (>20%) in the Americas and Europe, and as of Arizona, Tucson, AZ, USA. much as 30% in Brazil, Denmark, and Norway (4). 4 Professor and Chairman, School of Hygiene and Public Health, Even if the rates may be declining in some countries, Johns Hopkins University, Baltimore, MD, USA. there are signs that — owing to aggressive marketing 5 New York Liaison, WHO/Framework Convention on Tobacco Control Project, Campaign for Tobacco Free Kids, Washington, DC, USA. — the rates among women are rising, particularly in developing countries. Ref. No. 00-0604 Bulletin of the World Health Organization, 2000, 78 (7) # World Health Organization 2000 891 Special Theme – Tobacco Surveys in many industrialized countries have subarachnoid haemorrhage. Over a dozen prospective shown that rates of smoking among young women studies and numerous case–control studies have aged 14–19 years are comparable to or higher than reported that smoking is one of the major causes of those among young men (5). Rates are also rising in coronary heart disease in women (31–38). many countries in the South-East Asia and Western Women who use oral contraceptives have a Pacific Regions, where smoking is a symbol of particularly elevated risk of CHD if they smoke women’s liberation and freedom from traditional (39, 40). Earlier studies found that the risk was 20- to gender roles. Moreover, there is a popular belief 40-fold greater among women who both used oral among some young women that smoking keeps them contraceptives and smoked heavily, compared with slim. There is even greater cause for alarm because women who neither smoked nor used oral contra- the statistics on cigarette consumption do not reflect ceptives (41, 42). More recent studies based on newer the widespread use of smokeless tobacco among formulations of oral contraceptives show that the rural women. In India, for example, 22% of rural overall risk of CHD associated with oral contra- women in Kerala chew tobacco in pan (betel leaf). ceptive use is lower than was observed with the first- Women also smoke bidis (small indigenous cigar- generation formulations; however, the relative risk ettes) and hookahs, as in Bihar and parts of Punjab among smokers, particularly heavy smokers, who use and Hariyana, and rural women in Goa are known to oral contraceptives is still considerably higher than rub and plug the inside of their mouths with burnt that of non-smokers who do not use oral contra- powdered tobacco (6). ceptives (43–45). Table 1 summarizes the health risks for women In 1995, an estimated one-third of all cancer who smoke. Compared with non-smoking women, deaths in developed countries (47% of male cancer smokers are more likely to experience primary and deaths and 14% of female cancer deaths) was secondary infertility (7, 8) and delays in becoming attributable to smoking (46). The proportion of pregnant (9–12). With respect to pregnancy outcomes, tobacco-attributable cancer deaths is currently lower women who smoke are at increased risk of premature in developing countries (47), reflecting lower smok- rupture of membranes, abruptio placentae (premature ing prevalences in these countries in the past. By separation of the implanted placenta from the uterine 1990, lung cancer had become the third ranking cause wall), placenta previa (partial or total obstruction by of cancer mortality among women globally (48). the placenta of the cervical os), and preterm delivery Between 1950 and 1995 the lung cancer mortality (13–30). Moreover, their infants have lower average rates per 100 000 women in the USA rose steadily birth weights and are more likely to be small for (Fig. 1). The age-standardized lung cancer mortality gestational age and are at increased risk of stillbirth and rates for women aged 15–64 years in 1990, by world perinatal mortality compared with the infants of non- regions, are shown in Fig. 2. Risks for many other smoking women. Women who smoke also have an cancers are increased in women who smoke, increased risk of cardiovascular diseases, including including cancers of the mouth and pharnyx, coronary heart disease (CHD), ischaemic stroke, and oesophagus, larynx, bladder, pancreas, kidney, cervix, and possibly other sites. Although an effect of smoking on bone density Table 1. Health risks for women who smoke has not been consistently demonstrated among premenopausal or perimenopausal women, many Women who smoke have an increased risk of studies have found that postmenopausal women who . Primary and secondary infertility smoke have a lower bone density than non-smokers . Delay in conception (49–54). Cohort studies of smoking in relation to hip . Adverse pregnancy outcomes: fractures in women have reported multivariate- premature rupture of membranes adjusted relative risks ranging from about 1.2 to 2 abruptio placentae (55–59). There are fewer studies, with less consistent placenta previa results, of the association between smoking and the preterm delivery lower-birth-weight infant risk of fracture at sites other than the hip. small infant (for gestational age) stillborn infant Environmental tobacco smoke: death of infant in perinatal period a women’s issue . Cardiovascular diseases, including Tobacco smoking has been and still is primarily a coronary heart disease custom and an addiction of men, leaving women and ischaemic stroke children as the majority of the world’s passive or subarachnoid haemorrhage involuntary smokers. This is particularly pertinent to . Cancers, including women in the developing countries of the South-East lung, oesophagus, mouth and pharynx, bladder, pancreas, kidney, cervix Asia and Western Pacific Regions, the Eastern of uterus Mediterranean Region, and the Caribbean, where . Chronic obstructive pulmonary diseases, including rates of smoking for women have traditionally been bronchitis and emphysema low compared with those of men. Smoking (passive . Hip fracture or involuntary) is therefore still a ‘‘women’s issue’’ 892 Bulletin of the World Health Organization, 2000, 78 (7) Women and tobacco because of the negative impact of environmental tobacco smoke (ETS) on the health of women and children.